NEW YORK (Reuters Health) – A large proportion of pediatric patients undergo tonsillectomy and adenoidectomy in ambulatory settings, including some who should be treated in the hospital, according to researchers from Stanford University in California.

“Our study demonstrated that most patients with multiple comorbidities predictive of postoperative airway, respiratory, and cardiovascular complications were being appropriately triaged toward inpatient settings, where they could be more optimally managed,” study coauthor Dr. Kay W. Chang told Reuters Health by email.

“There were, however, a small number of patients that had identified comorbid risk factors such as young age and/or airway comorbidities (who had surgeries) performed as outpatients, and these patients had significantly higher complication rates. As economic incentives increase for ambulatory outpatient surgery center care, it is important to identify these vulnerable populations so that they are triaged appropriately,” Dr. Chang added.

Dr. Chang and colleagues reviewed the medical records of 115,214 children who underwent tonsillectomy and adenoidectomy (T&A) in hospitals, hospital-based facilities (HBFs), and free-standing facilities (FSFs). A total of 18,622 were treated as inpatients (mean age, 5.4) and 96,592 were ambulatory patients (mean age, 7.6).

Inpatients had up to eight comorbidities, compared with up to four for patients treated in HBF and no more than three in any FSF patient.

Complication rates varied by age and facility type, but generally, rates for inpatients were two to five times higher than for patients in HBFs and more than 10 times higher than for FSF patients. Inpatients up to nine years of age experienced higher rates of airway and respiratory complications, with those ages 0-11 months experiencing the highest rates of airway complications.

“Our results show that most patients undergoing T&A are cared for in an ambulatory setting, with many cared for in FSFs. Although most of the youngest patients underwent surgery in hospitals, 2,883 of 8,719 patients younger than 3 years (33.1%) were not admitted after surgery, and 396 (4.5%) were treated in FSFs. This distribution occurred despite guidelines from the AAOHNS (American Academy of Otolaryngology – Head and Neck Surgery) and American Academy of Pediatrics recommending admission for patients younger than 3 years,” the authors wrote in an article online February 25 in JAMA Otolaryngology – Head and Neck Surgery.

Commenting by email, Dr. Paul Krakovitz, a pediatric otolaryngologist at Cleveland Clinic Children’s, told Reuters Health, “This large study validates the guidelines AAP and AAOHNS set forth for admission criteria. What helps ensure the vulnerable young child is appropriately treated as an inpatient is following the guidelines. Those children who are either under the age of 3, have severe sleep apnea, or have other complex medical conditions need to be observed in a hospital for at least one night.”

The authors reported no funding or disclosures.


JAMA Otolaryngol Head Neck Surg 2016.